1. Chapter 3 Legal and Ethical Issues
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

2. Topics Scope of Care Patient Consent and Refusal Other Legal Concerns
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

3. Scope of Care
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

4. Scope of Care Legal Duties Ethical Responsibilities
These will be discussed in the next few slides
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

5. Scope of Care Legal Duties State law Local protocols
National standard curriculum
Advise the students that local protocols will guide their patient care, but that the local protocols must fall within the guidelines of the national standard curriculum. State law may also restrict what the first responder is allowed to do.
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

6. Scope of Care Ethical Responsibilities
The needs of the patient are the priority
Practice your skills to mastery
Uphold the standards and continue your education
Review your performance and report with honesty
Work in harmony with other members of the health care team
Stress that after the safety of the crew is addressed, than the needs of the patient are the priority
Make sure that the students realize that practice makes permanent, perfect practice makes perfect. When they practice, make sure that they do not take short cuts, of they will make those same mistakes when it counts the most.
Tell them how they can find the requirements for recertification in their state. Stress that this is a minimum amount of continuing education, and that they should obtain CE in as much as possible.
Advise the students that they should take part in some form of peer review or continuous quality improvement program to help ensure that they are always striving to do the best for their patients
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

7. Patient Consent and Refusal
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

8. Patient Consent and Refusal
Patient Competence
Patient Consent
Advance Directives
Patient Refusal
These topics will be discussed in future slides
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

9. Patient Consent and Refusal
Patient Competence
Capable of an informed decision
Must be competent to refuse treatment
CANNOT have any of the following:
Under the influence of drugs or alcohol
Altered mental status
Illness or injury that would affect judgment
Mentally ill
Patient competence is an important part of the first responders assessment as it will determine to what extent the first responder is able to help the patient
An informed decision is one in which all potential problems the patient may encounter have been addressed and then the patient is allowed to determine whether or not they wish to receive treatment
Stress that, in order to make an informed decision, the patient cannot have medical problems that could impair a rational decision
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

10. Patient Consent and Refusal
Must be obtained prior to treating a patient
Expressed
Implied
Children and mentally incompetent adults
Advise the students that, once they determine if a patient is competent, then they must obtain consent from the patient prior to treatment
Remind the students that they should always act with the patients best interests in mind
The types of consent will be addressed in more detail in the next few slides
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

11. Patient Consent and Refusal
Expressed Consent
Consent by the patient
Can be oral or through gestures
Must include risks
Must be in terms the patient can understand
Do not use medical terminology
Describe expressed consent as consent where the patient agrees to be treated
Even the mentally competent adult does not need to specifically state that they wish to be treated
Make sure the student understands the need to explain the risks to the patient and that they are aware that they should not use complex medical terminology when talking to the patient
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

12. Patient Consent and Refusal
Implied Consent
The law assumes that an unresponsive patient would want help if they could ask
Can be revoked if the patient returns to a normal level of consciousness
Also applies to those who are not competent to decide
Implied consent is described as consent where the patient is unable to make a decision regarding consent. The first responder assumes that, if the patient where able to make this decision, they would want to be treated.
Stress that implied consent can be revoked at any time if the patient returns to a normal mental status
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

13. Patient Consent and Refusal
Children and Mentally Incompetent Adults
A parent or guardian may give expressed consent
Implied consent would apply if a parent or guardian is not available
Minors may be emancipated
Does not require a parent or guardian
Laws may vary state to state
Advise the students that with children and mentally incompetent adults, all attempts should be made to reach a guardian or caregiver. If one can not be reached, then it is assumed that, if one could be reached, they would agree to the treatment.
Discuss emancipation with the students. Typically a minor may be emancipated through a court order or after giving birth to a child.
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

14. Patient Consent and Refusal
Advance Directives
Must be signed by the patient and the physician
Allows the first responder to withhold resuscitation
Must be clear and concise
Can dictate specific treatments
If in doubt, resuscitate
Advise the student that advanced directives are written by the physician and patient, and they outline what level of care the patient wishes to receive
Make sure that the order is signed by a physician, and that the orders are clear. “No Heroics” is not clear, especially since the heroics they address are part of the job.
Remember to always keep the patients best interests in mind, and resuscitate
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

15. Patient Consent and Refusal
Prehospital DNR
Review this prehospital Do Not Resuscitate order with the students
Show the students the parts of the DNR that modify support and where the required signatures should be found
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

16. Patient Consent and Refusal
Patient Refusal (1 of 4)
A competent adult can refuse treatment for themselves or for a minor at any time
Allow ambulance to continue to the scene for documentation
Continue to try to convince the patient to accept treatment
Confirm that the patient is competent
Make sure that the students understand that a competent patient always has the right to refuse any or all treatments
Stress that as a first responder, it is always recommended to have an ambulance respond to the scene. There is always the potential that the patient may get worse or something may cause them to change their mind.
Advise the students that, despite a child’s condition, the parent or legal guardian also has the right to refuse treatment for that child
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

17. Patient Consent and Refusal
Patient Refusal (2 of 4)
Consult medical direction if in doubt
Have the patient sign a release from reliability form
Advise the patient to seek help if there are any changes
Consider having a witness also sign
Remind the students that, if they feel a patient needs to go to the hospital and they are refusing, the first responder can call the physician in the emergency department to see if they can convince the patient to accept treatment
Always have the patient sign a form that releases the responders and the agency they work for from liability
Make sure that the first responders stress that the patient can always change their mind and call back
It is also advisable to have a family member or police officer sign agreeing that the patient was competent and refused treatment
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

18. Patient Consent and Refusal
Patient Refusal (3 of 4)
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

19. Patient Consent and Refusal
Patient Refusal (4 of 4)
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

20. Other Legal Concerns
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

21. Other Legal Concerns Assault and Battery Abandonment and Negligence
Confidentiality
Good Samaritan Laws
Preservation of Evidence
Special Documentation
These topics will be discussed in future slides
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

22. Other Legal Concerns Assault Battery Threatening physical harm
Unlawful physical contact
Warn the students that treating a competent patient against their will can result in assault and battery charges
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

23. Other Legal Concerns Abandonment
Leaving a patient without ensuring the same or higher level care
May be asked by PD to leave the scene
As a first responder, the students are able to pass of care to any other responding medical personnel. However, stress that the first responder should never leave a patient that have initiated care on unless they transfer care to another EMS provider.
Advise them that the police or fire departments can tell the first responder that the scene is not safe and can ask them to leave the scene. This would not constitute abandonment.
Remind the students that triage during a multiple casualty incident also does not constitute abandonment
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

24. Other Legal Concerns Negligence
Whenever your care deviates from standards and causes further harm
Must meet 4 criteria:
There was a duty to act
Must provide care when at work
Care must follow accepted guidelines
There was a breach of duty
The patient was injured physically or psychologically
The provider caused the injury
Stress that threats of negligence is reason why the first responder should always act within their scope of practice, only doing what they are trained to do, and never doing any less than their best
Stress the 4 criteria that must be met to prove negligence against the first responder, especially that the injury that results must be directly associated with the care provided by the first responder
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

25. Other Legal Concerns Confidentiality
Patient information is confidential
Can be released to another health-care provider for continuity of care
When requested by PD for a criminal investigation
You are required by a legal subpoena
HIPAA and Protected Health Information
Stress the importance of maintaining patient confidentiality both during and after a call
Most departments have a written policy regarding release of information to law enforcement. Usually information can only be given to law enforcement through written request or subpoena.
Review HIPAA legislation with the students
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

26. Other Legal Concerns Good Samaritan Laws
Can protect the First Responder as long as actions are not grossly negligent
Does not prevent a lawsuit; just offers protection against losing
Address Good Samaritan laws with the students. Advise them that they typically only apply when providing care when not at work, when there is not a duty to act.
The best way to avoid a lawsuit is to make sure that the first responder always provides care to the best of their ability
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

27. Other Legal Concerns Preservation of evidence
Your safety is your first concern
Once safe, patient care becomes the priority
Document anything unusual
Only touch what is necessary for patient care
Do not cut through holes in clothing
Do not allow rape victims to wash, change, or use the bathroom
Remind the student that the safety of the first responder and then patient care are always the priority, but that, on a crime scene, it is important to minimize the potential destruction of evidence
If something must be moved to provide patient care, advise law enforcement what was touched so that they know how to document it appropriately
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

28. Other Legal Concerns Special documentation
Must report injuries that are the result of a crime
Abuse
Gunshots
Stabbing
Poisoning
Exposure incidents
Dog bites
Attempted suicides
Advise the students that what must be reported may vary by state, but most typically, the dispatcher will handle the notification when the call comes in
In cases of abuse, make sure that the students relay any suspicions to PD if they are on scene, or to the members of the transporting agency so they can notify the appropriate staff at the hospital
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

29. Other Legal Concerns Special situations Medical ID tags
Organ donors and organ harvesting
Always provide life- saving care
Identifies patients as potential donors
Communicate with medical control
Advise the students that medical alert tags may help provide important information especially if a patient is unable to provide that information due to their current mental status
These tags may be found either on the wrist or around a patient’s neck
Organ donation varies by state, and most require more than just a notation on a drivers license, however this may be used to tell the family so they can make an appropriate decision regarding organ donation
Always try to resuscitate a patient that needs resuscitation
Do not resuscitate an obviously deceased patient just for the purpose of potential organ donation
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

30. Summary (1 of 2)
Provide treatments based on the scope of care as outlined by the DOT National Standard Curriculum
Make sure that you obtain patient consent
Understand a patient’s right to refuse care, and ensure proper documentation
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

31. Summary (2 of 2) Review Do Not Resuscitate orders for your state
Beware of assault, battery, negligence, and abandonment claims
Good Samaritan Laws
Patient confidentiality rules
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ